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| Alison Parsons is the Nursing Unit Manager on St. Clare's Ward (Geriatric Assessment Unit), St. Vincent's Hospital, Sydney. |
This paper highlights the perceptions and attitudes of health workers that may be detrimental to the care of elderly people. The literature suggests a widespread negative attitude to older people, based upon negative myths and stereotypes and perpetuated by the media's lack of understanding of anything of the ageing process or the potential of older people.
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Australia's population is ageing. The Australian Bureau of Statistics estimates that the population aged 60 years and over will be 16% (approximately 3 million) by 2001, and 22% (approximately 5 million) by 2021 (Kendig and McCallum, 1986: 4). The estimated expenditure on persons aged 60 years and over for 1987-88 was 1892.4 million dollars (Kendig, 1989: 137-140).
Laurent (1990: 20) commented on attitudes to old people in Great Britain, that they are regarded as "stupid, decrepit, feeble, or unusually eccentric, wise or sweet natured, and in any event to be patronised." She then referred to a report from the King's Fund that claimed that "...such attitudes (as above) pervade the health service and mean that services are based on deep seated stereotypes of what old people are like, rather than what they need or want." The article went on to note that often the elderly are "fobbed off" by health professionals because age alone is responsible for their ills, and that caring for the elderly is low-status work. Treharne (1990: 777) reported, again from Great Britain, that care of the elderly is an unpopular field in most clinical careers, including clinical psychology, medicine and social work. This unpopularity is no less so amongst nurses, and although the elderly were recognised as the most needy, disadvantaged group of patients, there was not a willingness to work in the area. Jones (1988: 10) in her research identified that, "...generally held negative stereotypes and prejudices reinforce discriminatory practices. Government's and employers' use of discriminatory age limits confirm the stereotypes" and "in effect, age discrimination is the denial of equal opportunity on the basis of incorrect assumptions about abilities and needs. Incorrect assumptions for generalisations about chronological age groups. Any age group can be affected in this way."
Lawton (1985: 115) claimed that "nowhere is the attitude against ageing more manifest than among the health professionals," primarily because not all of them have recognised gerontology as a specialty. Even today the print media and government are discussing age discrimination. Cillian McFee of the Office on Ageing said in the Sydney Morning Herald (1992: 16) that many older people feel rejected by a society that views them as worthless due to their age.
Collison (1992: 2) wrote "unfortunately our society still tends to hold negative attitudes about ageing and the aged." Little research has been done on nurses' attitudes to the elderly, but Collison has suggested that nurses' attitudes toward the elderly reflect those of society in general.
Many health workers think that patients are too old to learn or to understand. Too old to make decisions about care and too old to be responsive to the environment: just too old for care (Seymour 1991: 26).
0thers see all elderly people as an increasing burden on society because they are unproductive, increasingly frail, and vulnerable with their decreasing ability to perform activities of daily living, and frequently poor mobility. The health care system has a great emphasis on cure of disease rather than care of the individual. Seymour (1991: 27) wrote "cure refers to diagnosis and treatment of disease whereas care refers to the assessments and interventions used to make judgements about the well being of the person." Cure is often implemented by doing things to a patient. Care is fundamentally offered by doing things with the patient. Health workers, and nurses in particular, must ask "what are the basic needs for care that individuals have when the goal of cure can no longer be met?"
Jackson (1989: 907) wrote that an American study supported the evidence that attitudes to patient assessment and teaching are poorly regarded. Although nurses agree that elderly patients have a right to know and be taught, they thought their own older patients were too old to learn or to understand new information.
Ageism refers to a systematic discrimination toward a group of people based on chronological age (Matteson & McConnell, 1988: 1). Ageism is "a process of systematic stereotyping of and discrimination against people because they are old... Ageism allows the younger generations to see older people as different from themselves, thus they subtly cease to identify with their elders as human beings." (Butler, 1975, cited in Matteson & McConnell, 1988: 482). Matteson and McConnell (1988: 482) point out that ageism decreases social status, and diminishes contact with younger people. It affects the health care of older people by influencing the attitudes of health care professionals and policy-makers towards the aggressiveness of diagnosis and treatment of the elderly. These attitudes are often based on erroneous assumptions regarding the utility of chronological age as a marker of function or ability to contribute to society. The tragedy of ageism is that it robs society of the fullest contributions of its older members, and it denies people's fulfilment of their potential as human beings throughout the life course.
In the United States Buckwalter, South, and Martin (1993: 55) documented that ageism may prevent elderly people from receiving adequate mental health care, and that mental health workers, particularly, have declined to promote therapy or treatment for elderly people. The study shows that elderly people are considered unsuitable for treatment due to their age, or that they suffer from the "normal" problems of ageing. Apparently some of these attitudes and beliefs are reinforced by poor education and poor understanding of the elderly. All health care workers caring for the elderly have a responsibility to confirm their own biases, perceptions, values and beliefs relating to the work that they do.
Cook (1992: 292) asks whether ageism is the devaluation of older persons and the holding of discriminatory attitudes, or whether it is lack of knowledge about older people and the ways in which the elderly population is changing demographically. Stereotyping is an easy trap to fall into, and anyone who has anything to do with the elderly knows that they are a heterogeneous group encompassing every facet of life in a span of about 40 years.
Negative myths and stereotypes are at the heart of age discrimination. Older people are often portrayed as frail, tired, self-pitying, dull, unhappy, intolerant and unproductive, and yet many have been most useful in society and capable of much more but not allowed to develop or contribute their skills and potential.
The media have a great influence on beliefs and attitudes. The media present positive and negative attitudes. They may educate the elderly and community in general, but they may sensationalise a story or present information out of context that may create confusion. "Some information about ageing-related events may be accurate but discouraging: stories that dwell on the burdens associated with ageing and reinforce the myth that all elderly people are dependent. The way elderly people are represented in the media can greatly affect the public's perception of ageing, for example, the specific choice of words used to refer to an older person can convey a strong negative connotation." (WHO, 1989: 77).
Williams (1989: 8) in an address said that "old age is not an ideal state, only the best of possible choices." The role of the older person as seen by the media, may be very demeaning. Williams (1989: 8) asserts that Australians, as a whole, believe that the elderly should live in a limited way, often stripped of possessions, bereft of status symbols, and have no say in the community.
It is said that Australia has one of the "oldest" populations in the western world. The elderly are the greatest users of the health system, so it is an advantage to provide care, support and assistance in the best possible way, with proper positive attitudes. It is quite normal for many people to live for 20 to 40 years after retirement, so it is essential that they are assisted to have a rich quality of life in the best health possible. This means independence, or near independence will be maintained, and if they are hospitalised, their good health possibly ensures a speedier, stronger recovery. Many elderly people hold distinguished, high profile positions all over the world; many retire and commence a new career, and others certainly develop new interests. They must be encouraged and allowed to develop and contribute their skills and potential, not be squeezed "out of sight, out of mind."
As people age they adjust to their disabilities when necessary, they omit or compromise on some activities, go slower but still participate mentally and physically when they want to or are required to. The elderly have developed, over a lifetime, characteristics that are particular to them. There are some well documented medical and nursing texts describing normal changes with ageing affecting physical appearance, stature, senses (vision, hearing, teeth and smell), appetite and digestion, tactile sensation and skin, sexual activity, and sleep. Most people could tell you some or all the changes, but they may not be right - there are normal changes, but the broad community also assumes some changes are normal when that is not so, there are myths as well.
The elderly are quite capable of absorbing new information and increasingly are participating in further study. Jones (1989: 12) wrote that learning differences are not appreciable until 70 years and over. Some people do not have mental agility, because they do not need it following retirement. Their reaction times are decreased which leads to the assumption of mental slowness. Henderson and Jorm (1986, cited in Jones, 1989: 12) found that Alzheimer's Disease and other dementias affected less than 1.9% of people 65-69 years old and 29% of 85 years and over. Therefore the majority of older people are not affected. Most of the elderly are fit, and mentally and physically healthy. For many it is a time of advantages: to enjoy doing new things, spending time with family and friends, developing new interests, many doing volunteer work. They are not a homogeneous group, as some would like to think, they span 40-50 years, and are from a great variety of backgrounds, cultures and religions.
It is essential for everyone to understand that the elderly are worthwhile; that they are worth treating; that they are people. Treatment may not be as aggressive as for a younger person, and it must be recognised that the elderly are slower, so they need more time and consideration. This is practised in specialist gerontology areas, but the elderly are the majority of patients in many hospitals, so they are in other wards or units as well. Staff in these areas are known to suggest that they be handed to the geriatric team or ward as soon as possible, sometimes for good reasons, but sometimes because they are seen to be "difficult", or not worth any more consideration.
A policy on Ageing in New South Wales has been drafted by Kendig stating that "there is no simple age when people 'become old', nor is there any homogeneous group of old people... older people's desires to remain independent and contributing members of society cannot be fulfilled when opportunities are closed off on the basis of age alone. The experience of ageing depends heavily on the attitudes to and treatment of old people... by younger members of the community" (Kendig, 1989: 9). In Australia, for practical purposes, old age commences at 60 years and old "old" is 75 years and over (Kendig & McCallum, 1986: 1).
Ahmed, Kraft and Porter (1986: 77) in their study of attitudes towards geriatric patients, maintain that the attitudes of professional workers toward the elderly will affect the type and quality of care provided for them, and that attitudes of health professionals toward elderly persons should be positive (1986: 85). Dans and Kerr (1979, cited in Ahmed et al., 1986) thought that accurate knowledge and positive attitudes were essential. while Kampmeier (1985, cited in Ahmed et al., 1986: 85) contends that every doctor should be knowledgeable of the course of ageing, irrespective of his or her specialty.
Educators and practitioners alike, seem to agree that there must be more gerontological content in nursing curricula because researchers have found nursing student's attitudes to the elderly to be more negative than positive (Spier, 1992: 520). It seems that poor attitudes are similar around the world; these must be changed, and education is probably the best means to promote a better image. In a hospital with geriatric services, it seems sensible to expect that when there are elderly patients who must remain in a specialty area, that the geriatric service can be used as a resource. In this way, other staff can learn to understand the elderly better. These patients can be fun, serious, sad, happy, complex, demanding, wise, generous, trying, helpful, anything anyone else can be, so they deserve good holistic care.
The persistence of negative attitudes perpetuate the myths, which is a tragedy when the majority of elderly people live at home, lead purposeful lives, and often see their contemporaries as old, but not themselves. With the aged population increasing, and the government's financial "cake" decreasing, it means that there will be less money for pensions and other assistance. The negative view of the elderly which has developed probably due to the image of youth and vitality promoted particularly by the media, must change. Old people should feel valued, be respected for their knowledge and experience, and be given opportunities to make choices. Possession of good health is probably the most important element for a meaningful old age, because it induces activity. The elderly must not be seen as a decrepit, debilitated lot, draining the country's resources, but as useful, contributing members of our society.
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